Unfit for care: How blood pressure cuffs can participate in health disparities

Modern public health efforts have wrestled with high blood pressure for decades. Approximately one-third of adults over 35 years old have hypertension in North America (Wolf-Maier et al., 2003), which amounts to over one billion people at risk for severe cardiovascular complications. A closer look at the data indicates hypertension disproportionately impacts racial minorities and rural geographies (Kershaw et al., 2010). 

The privilege of ready access to a family doctor and a nutrient-rich, balanced diet are vital preventative measures against hypertension, and are often not a reality for racial and ethnic minorities who face intersecting socioeconomic and geographical inequities (Kneebone & Reeves, 2016. The industrialization of food production has led to cheap ultra-processed foods that bundle profits for food production and food service sectors at the expense of public health, leading to disparities in hypertension among other conditions (Barbosa, 2022). Options for lower income families can be limited to high-sodium, high-sugar products that are not only affordable, but also more suitable in households of people working long hours with low wages (Barbosa, 2022). In addition, the psychological stress of experiencing racism can raise blood pressure, and a handful of literature dives into the mechanisms of yet another example of the interconnectedness of mind and body health (Cohen et al., 2015). 

To make matters worse, the tools we use to address a patient’s blood pressure may be contributing to these health disparities. Blood pressure monitoring cuffs are key to not only diagnosing hypertension, but also for at-risk people to monitor their health at home. However, a recent study found over-the-counter blood pressure monitoring cuffs do not consistently fit properly. In fact, they estimate over 17 million adults across the United States have not been provided with a cuff that fits correctly on their arm (Kaur et al., 2024). 

(Unsplash / Mockup Graphics)

Hypertension is diagnosed when the systolic number, on the top of the display, reads over 130, or when the diastolic number exceeds 80. For reference, a normal blood pressure reading ranges from 90/60 to 120/80 (Kaur et al., 2024). In the event that a cuff is too large compared to the circumference of the arm, the individual’s blood pressure is underestimated on the systolic scale by up to 4 units (Kaur et al., 2024). This is a seemingly small margin, however given the numeric boundary that defines hypertension, this can lead to underdiagnosis that affects how patients and their healthcare teams respond (Ishigami et al., 2023). Although a misdiagnosis of prehypertension can still provoke adequate prevention efforts, of more concern is if cuff readings return a healthy blood pressure when the real value falls in the prehypertensive range. Kaur et al. (2024) find that the home blood pressure monitoring cuffs are two times as likely to fit improperly on Black adults’ arms, and Black adults are already 30% more prone to hypertension than the rest of the population (Shrivastava et al., 2024). 

Blood pressure overestimations do not necessarily constitute a safety net, but they come with unnecessary anxiety and challenges for patients. Kaur et al. (2024) find that cuffs too small can overestimate up to 20 units. Overdiagnosing hypertension brings people excessive stress and anxiety, and can be overwhelming for people who are monitoring progress from home for their efforts to ensure their measurements lie in healthy ranges.

(Unsplash / Hush Naidoo Jade Photography)

Although home monitoring blood pressure cuff manufacturers do sell optional cuffs that have a greater size range than the defaults, they have to be purchased at an extra cost (Kaur et al., 2024). If those with authority in healthcare decisions and instruments actively engage with narratives of lives affected by cardiovascular health inequities, this may decrease overreliance on technologies like blood pressure cuffs or alert manufacturers to redesign them to be more appropriate across different populations.

By: Nik Thakker

Edited by: Christina Zeng (She/Her) | Blog Committee Member

References

Barbosa, S.S.; Sousa, M.; Franciole, D.; Jéssica Bastos Pimentel; Cavalcanti, K.; de, C.; Gomes, M.; Vieira, C. (2022) A Systematic Review on Processed/Ultra-Processed Foods and Arterial Hypertension in Adults and Older People. Nutrients 2022, 14 (6), 1215–1215. https://doi.org/10.3390/nu14061215.

Kneebone, E., & Reeves, R. V. (2016). The intersection of race, place, and multidimensional poverty. Brookings. https://www.brookings.edu/articles/the-intersection-of-race-place-and-multidimensional-poverty/

Cohen, B. E., Edmondson, D., & Kronish, I. M. (2015). State of the art review: Depression, stress, anxiety, and cardiovascular disease. American Journal of Hypertension, 28(11), 1295-1302. https://doi.org/10.1093/ajh/hpv047

Ishigami, J., Charleston, J., Miller, E. R., Matsushita, K., Appel, L. J., & Brady, T. M. (2023). Effects of cuff size on the accuracy of blood pressure readings. JAMA Internal Medicine, 183(10), 1061. https://doi.org/10.1001/jamainternmed.2023.3264

Kaur, E., Rayani, A., Brady, T. M., & Matsushita, K. (2024). Arm Size Coverage of Popular Over-the-Counter Blood Pressure Devices and Implications in US Adults. Hypertension, 81(10). https://doi.org/10.1093/ajh/hpv047

Kershaw, K. N., Diez Roux, A. V., Carnethon, M., Darwin, C., Goff, D. C., Post, W., Schreiner, P. J., & Watson, K. (2010). Geographic variation in hypertension prevalence among blacks and whites: The multi-ethnic study of atherosclerosis. American Journal of Hypertension, 23(1), 46-53. https://doi.org/10.1038/ajh.2009.211

Srivastava, A., Mirza, T. M., Sarosh Vaqar, & Sharan, S. (2024, March 4). Prehypertension. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538313/

Wolf-Maier, K., Cooper, R. S., Banegas, J. R., Giampaoli, S., Hense, H. W., Joffres, M., Kastarinen, M., Poulter, N., Primatesta, P., Rodríguez-Artalejo, F., Stegmayr, B., Thamm, M., Tuomilehto, J., Vanuzzo, D., & Vescio, F. (2003). Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA, 289(18), 2363–2369. https://doi.org/10.1001/jama.289.18.2363